Assessment of efficacy of CPAP/Any PAP TherapyAssessment of efficacy of Oral Appliance TherapyAssessment of efficacy of SurgeryAssessment of efficacy of other treatmentRe-evaluation of OSA is needed to continue therapyOtherNONE

Sleep Assesment

NoTried, but could not complete itYes, less than 2 years agoYes, more than 2 years ago

I have tried CPAP before *

NeverTried, but could not tolerate itI am currently using CPAP

I wake with dry mouth or throat *

NeverOccasionallyFrequentlyEvery Day

I wake up in the middle of the night *

NeverOccasionallyFrequentlyEvery Night

I usually wake up to urinate *

NeverOnceTwiceThree or more times

At night, I usually wake up *

Almost neverOnce a nightSeveral times a nightMore than 3 times a night

Epworth Sleepiness Scale:

Do you get sleepy, or doze off while sitting & reading? *

Never doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

Do you get sleepy, or doze off while watching TV? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

While sitting or inactive in a public place (meeting, theater)? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

As a passenger in a car for an hour without a break? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

Lying down to rest in the afternoon? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

Sitting and talking to someone? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

Sitting quietly after lunch without alcohol? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

In a car, while stopped for a few minutes at a traffic light? *

Never would doze offSlight Chance of dozingModerate Chance of dozingHigh Chance of dozing

STEP 2:Scheduling a call back from aneSNORE & SLEEPtechnician

Thank you for completing our questionnaire. A technician will contact you to review this questionnaire and discuss the next steps in the process.Please indicate which day that you are available for a brief call, and choose a one hour window when the technician can contact you. For example: (Tomorrow or 2 Days From Now) and (9:00 am to 10:00 am).